Type 2 Diabetes: From Old Dogmas to New Realities

Over the last decade, dramatic changes have occurred in our understanding of the onset and progression of prediabetes. Lightning speed changes have also occurred regarding the therapies available to achieve optimal blood glucose control. Even with all of this change, however, many old dogmas hang on. It’s time to become aware of the new realities. In this article, I focus on two common old dogmas and the new realities.

Old Dogma: Type 2 isn’t the serious kind of diabetes. People are typically diagnosed later in life, and they just need to follow a healthy eating plan and lose a few pounds. Perhaps, over the years, they’ll need a “diabetes pill.”

New Reality: Recent research underscores that type 2 is a progressive disease that typically begins nearly a decade before diagnosis. Insulin resistance due to excess weight, mixed with a positive family history, are the common culprits. Prediabetes and type 2 are now being diagnosed in younger adults and even in children.

By the time type 2 is diagnosed, most people have already lost half to three-quarters of their insulin-making pancreatic beta cells. The American Diabetes Association and the American Association of Clinical Endocrinologists now recommend starting on a blood glucose-lowering medication at the time of diagnosis. And this isn’t your grandmother’s diabenase or orinase (or any sulfonylurea), which puts more insulin into the circulation. The recommendation from both organizations is to start with a medication to treat the central problem in type 2–insulin resistance–to curb the production of glucose from the liver. The most commonly prescribed first drug to accomplish this goal is metformin.

It’s now known that patients’ insulin production will dwindle further over the years. Most people will need a progression of blood glucose-lowering medicines to make the best use of the insulin they continue to make. As the saying goes, if you live long enough with type 2, you’ll need to take insulin.

Experts now know that prediabetes and type 2 are about a lot more than simply insulin and glucose. Many other hormones and organs are involved. To learn more, read my article in Diabetic Living, “How to Lower Morning Highs.” The good news? Research shows that early, aggressive management to control blood glucose can slow disease progression. To learn more, read my article in Diabetic Living, “Treat Early, Treat Often.” While medications are important for glucose control, healthy eating, losing a few pounds, and being physically active always offer a big assist.

Old Dogma: Blood glucose control is goal number one, and diabetes is all about glucose control.

New Reality: The most common complications of type 2 are heart and blood vessel diseases, not blindness, kidney disease, or an amputation, as is the common notion. Having type 2, it’s said, is an equivalent risk factor to having had a heart attack or stroke.

Research has shown that to get and stay healthy over time, people with type 2 need to focus squarely on their ABCs–“A” for glucose control (the A1C result), “B” for blood pressure, and “C” for blood cholesterol. Studies show that when people think diabetes, they think glucose. They don’t make the link between diabetes and circulatory problems. Yet three-quarters of people with diabetes have high blood pressure, and the most common cause of death for people with type 2 is heart attack or stroke.

Bottom line: The most important new reality for prediabetes and type 2 diabetes is: Take action as early as possible after diagnosis. Don’t delay, don’t deny. Get and keep your blood glucose, blood pressure, and blood cholesterol within recommended target zones.

Hope Warshaw, MMSc, RD, CDE, is a nutrition and diabetes consultant and the best-selling author of numerous consumer books, including Diabetes Meal Planning Made Easy, Real Life Guide to Diabetes, and Complete Guide to Carb Counting, all published by the American Diabetes Association.

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